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Re-Evaluation
A re-evaluation after 5 weeks of therapy shows a wound with a mixed tissue composition: 40% slough, 40% granulation, and 20% epithelialization. What treatment adjustment would most likely promote further healing?
The presence of substantial slough alongside granulation tissue indicates that additional debridement is needed. Switching to a dressing that facilitates autolytic debridement may help remove remaining non-viable tissue and promote epithelialization.
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What findings during skin assessment indicate tissue tolerance problems that may lead to skin breakdown?
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Key findings include persistent erythema, non-blanchable erythema, skin temperature changes (warmth or coolness), edema, induration, maceration, dryness/flaking, denudement, and changes in skin turgor. Early identification of these tissue tolerance issues allows for interventions before skin breakdown occurs.
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Quiz
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Re-Evaluation
A re-evaluation after 5 weeks of therapy shows a wound with a mixed tissue composition: 40% slough, 40% granulation, and 20% epithelialization. What treatment adjustment would most likely promote further healing?
The presence of substantial slough alongside granulation tissue indicates that additional debridement is needed. Switching to a dressing that facilitates autolytic debridement may help remove remaining non-viable tissue and promote epithelialization.
